(These definitions apply when the following terms are used.)
The right granted to a doctor to admit patients to a particular hospital.
A specialized facility which is established, equipped, operated, and staffed primarily for the purpose of performing surgical procedures and which fully meets one of the following two tests:
An Ambulatory Surgical Center which is part of a Hospital, as defined herein, will be considered an Ambulatory Surgical Center for the purposes of this Plan.
A group. Often, associations can offer individual health insurance plans specially designed for their members.
Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
A specialized facility which is primarily a place for delivery of children following a normal uncomplicated pregnancy and which fully meets one of the following two tests:
Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. When patents run out, generic versions of many popular drugs are marketed at lower cost by other companies. Check your insurance plan to see if coverage differs between name-brand and their generic twins.
A period of one year beginning with a January 1.
The insurance company or HMO offering a health plan.
The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what it covered, what is not, and dollar limits.
A request by an individual (or his or her provider) to an individual's insurance company for the insurance company to pay for services obtained from a health care professional.
Co-insurance refers to money that an individual is required to pay for services, after a deductible has been paid. In some health care plans, co-insurance is called "co-payment." Co-insurance is often specified by a percentage. For example, the employee pays 20 percent toward the charges for a service and the employer or insurance company pays 80 percent.
Co-payment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some HMOs require a $10 "co-payment" for each office visit, regardless of the type or level of services provided during the visit. Co-payments are not usually specified by percentages.
Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your employer-sponsored coverage is otherwise terminated. For more information, visit the Department of Labor.
A facility which is primarily engaged in providing diagnostic, therapeutic, and restorative services to outpatients for the rehabilitation of injured or sick persons and which fully meets one of the following two tests:
Covered Health Services are those health services, supplies, or equipment provided for the purpose of preventing, diagnosing, or treating a Sickness, Injury, Mental Illness, substance abuse, or symptoms. Covered Health Services must be provided:
A Covered Health Service must meet each of the following criteria:
The Participant and the Participant's wife or husband and/or Dependent children who are covered under this Plan.
The amount an individual must pay for health care expenses before insurance (or a self-insured company) covers the costs. Often, insurance plans are based on yearly deductible amounts.
Refusal by an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.
Spouse and/or unmarried children (whether natural, adopted or step) of an insured.
A facility designated by the Company to render necessary Covered Services and Supplies for Qualified Procedures under this Plan.
The date your insurance is to actually begin. You are not covered until the policies effective date.
Medical care and treatment provided after the sudden onset of a medical condition manifesting itself by acute symptoms, including severe pain, which are severe enough that the lack of immediate medical attention could reasonably be expected to result in any of the following:
Emergency room services are covered only if it is determined that the presenting symptoms, as coded by the provider and recorded by the hospital on the UB92 form or its successor, or the final diagnosis, whichever reasonably indicates an emergency medical condition, shall be the basis for reimbursement or coverage, provided such symptoms reasonably indicated an emergency medical condition.
For the purposes of this policy, in accordance with the National Committee for Quality Assurance, an emergency medical condition is a condition such that a prudent lay-person, acting reasonably, would have believed that emergency medical treatment is needed.
This policy provides benefits for isolation care and emergency services provided by the state's mobile field hospital. The reimbursement rates paid will be equal to the rates paid under the Medicaid program, as determined by the Department of Social Services.
In addition, Emergency Care includes immediate Mental Disorder Treatment when the lack of the treatment could reasonably be expected to result in the patient harming him or her and/or other persons.
Essential Benefits include categories and the items and services covered within the categories:
The lifetime maximum of $1,500,000 does not apply to the benefits listed above.
Medical services that are not covered by an individual's insurance policy.
Medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time the Company makes a determination regarding coverage in a particular case are determined to be:
The insurance company's written explanation to a claim, showing what they paid and what the client must pay. Sometimes accompanied by a benefits check.
A "twin" to a "brand name drug" once the brand name company's patent has run out and other drug companies are allowed to sell a duplicate of the original. Generic drugs are cheaper, and most prescription and health plans reward clients for choosing generics.
Insurance issued to a consumer, regardless of the consumer's current health. It may be offered by companies with specialized high-risk offerings, or it may be mandated by state law. Usually, laws aimed at requiring guaranteed issue coverage also require that the coverage be given at a uniform fixed price.
A contract that the insured has the right to continue in force by the timely payment of premiums for a substantial period of time as set forth in the contract. During that period of time, the insurer has no right to make any change in any provision of the contract other than a change in the premium rate for all insureds in the same class.
Services, sometimes provided by insurance companies or employers, that help individuals weigh the benefits, risks and costs of medical tests and treatments. Unlike case management, health care decision counseling is non-judgmental. The goal of health care decision counseling is to help individuals make more informed choices about their health and medical care needs, and to help them make decisions that are right for the individual's unique set of circumstances.
Health Cooperatives have been proposed in the Senate as an alternative to a proposed government plan or public option. The cooperatives, which would be structured as non-profits and owned by their members, could offer a network of health care providers or contract out for medical services. The concept championed by some Democrats would provide "seed money" for the cooperatives, which would then be sustained by customer premiums.
An organized marketplace for the purchase of health insurance set up as a governmental or quasi-governmental entity to help insurers comply with consumer protections, compete in cost-efficient ways, and to facilitate the expansion of insurance coverage to more people.
Health Maintenance Organizations represent "pre-paid" or "capitated" insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided, Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs vary in design. Depending on the type of the HMO, services may be provided in a central facility, or in a physician's own office (as with IPAs.)
An agency or organization which provides a program of home health care and which meets one of the following tests:
An agency that provides counseling and incidental medical services for a terminally ill individual. Room and Board may be provided. The agency must meet one of the following tests:
An institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient's expense and which fully meets one of the following three tests:
Providers or health care facilities which are part of a health plan's network of providers with which it has negoiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.
Indemnity health insurance plans are also called "fee-for-service." These are the types of plans that primarily existed before the rise of HMOs, IPAs, and PPOs. With indemnity plans, the individual pays a pre-determined percentage of the cost of health care services, and the insurance company (or self-insured employer) pays the other percentage. For example, an individual might pay 20 percent for services and the insurance company pays 80 percent. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans offer individuals the freedom to choose their health care professionals.
IPAs are similar to HMOs, except that individuals receive care in a physician's own office, rather than in an HMO facility.
Health insurance coverage on an individual, not group, basis. The premium is usually higher for an individual health insurance plan than for a group policy, but you may not qualify for a group plan.
A person who specializes in Mental Disorder Treatment and is licensed as a Licensed Professional Counselor (LPC) or Licensed Clinical Social Worker (LCSW) by the appropriate authority.
A limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.
LOS refers to the length of stay. It is a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.
The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits vary greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year.
Health care services and supplies which are determined by the Company to be medically appropriate and are:
(For the purpose of this definition, the term "life threatening" is used to describe Sicknesses or conditions which are more likely than not to cause death within one year of the date of the request for treatment.)
The fact that a Physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, Sickness, mental illness or pregnancy does not mean that it is a Medically Necessary service or supply as defined above. The definition of Medically Necessary used in this policy relates only to coverage and differs from the way in which a Physician engaged in the practice of medicine may define medically necessary.
"Generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.
The Health Insurance for the Aged and Disabled program under Title XVIII of the Social Security Act.
Mental Disorder Treatment is treatment for the following:
All inpatient services, including Room and Board, given by a mental health facility or area of a Hospital which provides mental health or substance abuse treatment for a Sickness identified in the DSM, are considered Mental Disorder Treatment, except in the case of multiple diagnoses.
If there are multiple diagnoses, only the treatment for the Sickness, which is identified in the DSM, is considered Mental Disorder Treatment.
Detoxification services given prior to and independent of a course of psychotherapy or substance abuse treatment is not considered Mental Disorder Treatment.
Prescription Drugs alone are not considered Mental Disorder Treatment. In order to be considered treatment, the above listed criteria must be met.
A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.
A provider which participates in the network.
The basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.
A Hospital (as defined) which does not participate in the network.
A provider which does not participate in the network.
A person who is licensed or certified to practice as a Nurse-Midwife and fulfills both of these requirements:
A person who is licensed or certified to practice as a Nurse Practitioner and fulfills both of these requirements:
This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-plan health professionals may not be covered, or covered only in part by an individual's insurance company.
Services and supplies furnished to the individual and required for treatment, other than the professional services of any Physician and any private duty or special nursing services (including intensive nursing care by whatever name called).
A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses.
An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.
A person enrolled in one of the Association’s benefit plans.
A legally qualified:
The Participant's medical benefits described in this Booklet.
A medical condition that is excluded from coverage by an insurance company, because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.
You or your employer receive discounted rates if you use doctors from a pre-selected group. If you use a physician outside the PPO plan, you must pay more for the medical care.
A health care professional (usually a physician) who is responsible for monitoring an individual's overall health care needs. Typically, a PCP serves as a "quarterback" for an individual's medical care, referring the individual to more specialized physicians for specialist care.
Provider is a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.
A person who specializes in clinical psychology and fulfills one of these requirements:
As to charges for services rendered by or on behalf of a Network Physician, an amount not to exceed the amount determined by the Company in accordance with the applicable fee schedule.
As to all other charges, an amount measured and determined by the Company by comparing the actual charge for the service or supply with the prevailing charges made for it. The Company determines the prevailing charge.
It takes into account all pertinent factors including:
A facility accredited as a rehabilitation facility by the Commission on Accreditation of Rehabilitation Facilities.
A review and determination that the services and supplies are Covered Health Services.
Room, board, general duty nursing, intensive nursing care by whatever name called, and any other services regularly furnished by the Hospital as a condition of occupancy of the class of accommodations occupied, but not including professional services of Physicians nor special nursing services rendered outside of an intensive care unit by whatever name called.
The term "Sickness" used in connection with newborn children will include congenital defects and birth abnormalities, including premature births.
If the facility is approved by Medicare as a Skilled Nursing Facility then it is covered by this Plan.
If not approved by Medicare, the facility may be covered if it meets the following tests:
When a state passes laws requiring that health insurance plans include specific benefits.
A facility which provides a program of effective Mental Disorder Treatment and meets all of the following requirements:
The company that assumes responsibility for the risk, issues insurance policies and receives premiums.
An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.
A period of time when you are not covered by insurance for a particular problem.